摘要:

Currently, therapy of acute ischemic stroke includes general treatment, such as pulmonary function and airway protection, cardiac care and blood pressure management, fluid and electrolyte balance, treatment of elevated intracranial pressure due to brain edema and specific treatment, such as restitution of perfusion, maintenance of perfusion and increase of diminished blood flow, as well as prevention of ischemic cellular damage. In this article, the rationale for these therapeutic strategies is discussed and appropriate approaches to different subgroups of strokes are proposed. These include dissection of the carotid and vertebral arteries, basilar occlusion, middle cerebral artery occlusion, multiple transient ischemic attacks or slowly progressive stroke due to high-grade internal carotid artery stenosis and space-occupying cerebellar infarction. Despite the lack of generally accepted and scientifically proven therapies, many approaches seem promising. Individual concepts for defined stroke subgroups need to be verified in controlled prospective multicenter trials.

ISSN:1015-9770    

DOI:10.1159/000108903

出版商:S. Karger AG    

年代:1991

数据来源: Karger

摘要:

The lack of efficacy proof explains that there is no standard therapy for acute stroke. If we consider the stroke incidence and the number of drugs tested and developed in this indication for more than 30 years, what are the difficulties to reach therapeutic efficacy? The first is patient selection: hemorrhage and ischemia are not candidates for the same therapy; for cerebral infarcts, therapeutic implications are often specific of the etiologic mechanism (arterial embolism, thrombosis with developed atheroma, hypertensive microangiopathy). The right selection depends oh clinical criteria for stroke diagnosis before any emergency strategy; on imaging criteria (computed tomography and magnetic resonance imaging) for more precise type, area and extension of cerebral damage, and on cerebrovascular criteria (Doppler, arteriography) for stroke mechanism. Hemodynamic and metabolic criteria are of great interest but have no direct application for therapeutic trials. The second difficulty is the assessment of therapeutic effect. Survival can be the main criteria only for severe strokes. Neurological recovery assessment is difficult and can be comparative only for similar patterns of deficits. Functional recovery assessment is possible with validated scales but is more sensitive to confusion factors. Measuring the infarction size with neuro-imaging after the early stage is a promising approach but procedure and device standardization are still limiting factors, especially for multicenter trials.

ISSN:1015-9770    

DOI:10.1159/000108904

出版商:S. Karger AG    

年代:1991

数据来源: Karger

摘要:

Acute ischemic stroke remains a common medical condition without an effective therapy to reduce neurologic morbidity. Controversies persist about the value and role of intravenous and oral anticoagulants in acute-stroke management. Newer pharmacologic therapies for stroke intervention have been developed and many are presently being assessed in experimental models and human clinical trials. The first major category are thrombolytic agents, which attempt to restore blood flow to areas of focal cerebral ischemia. Other approaches to acute-stroke therapy are attempts to correct or reduce the cellular, biochemical and metabolic consequences of acute, focal, cerebral ischemia. Pharmacologic interventions with voltage-sensitive and receptor-mediated calcium channel inhibitors, free radical inhibitors and other agents have been reported. Many of these newer therapies appear to be promising and will hopefully prove to be beneficial.

ISSN:1015-9770    

DOI:10.1159/000108905

出版商:S. Karger AG    

年代:1991

数据来源: Karger

摘要:

Heparin therapy is currently used throughout industrialized countries to, treat the acute phase of stroke. It is astonishing to consider the disparity between the lack of large-scale multicenter controlled trials for heparin therapy and the proliferation of aspirin trials throughout the world. Perhaps with the launching of the new low-molecular-compound heparins, there will be opportunity to set up trial in order to try establishing the indications for early anticoagulation.

ISSN:1015-9770    

DOI:10.1159/000108906

出版商:S. Karger AG    

年代:1991

数据来源: Karger

摘要:

Eighteen patients were treated with 70 mg tissue plasminogen activator (t-PA) intravenously after the onset of acute severe cerebral ischemia: 10 suffered from vertebrobasilar occlusive disease and 8 had carotid territory strokes. In the former, reperfusion rates were poor (4/10) which was associated with a fatal clinical outcome in 7. In patients with internal carotid and middle cerebral artery occlusions, reperfusion rates were similarly low (3/7), 3 patients died from ischemia independent from the observed perfusional state and 1 suffered a fatal hemorrhage after infusion of less than 25 mg t-PA. Since many of the patients particularly with vertebrobasilar disease were somnolent or stuporous, an unfavorable delay between thrombosis and thrombolysis was suggested - in addition, since infarction was obvious on CT. In all, the dosage selected seemed to be too low to be efficient. Further investigations are required to test the benefit of earlier treatment (<4 h) with higher dosages of t-PA.

ISSN:1015-9770    

DOI:10.1159/000108907

出版商:S. Karger AG    

年代:1991

数据来源: Karger

摘要:

Intentional hemodilution has been shown to increase cerebral blood flow under normal conditions and in experimental stroke. Clinical trials of hemodilution in patients with acute stroke have employed dextran, hydroxyethyl starch or albumin as hemodiluting agents, often in combination with venesection. An overview of 12 randomized clinical trials of hemodilution in acute stroke (total 2,509 patients) shows no overall effect on survival (odds ratio 1.01 for active treatment:control). In surviving patients, neurological outcome is similar in hemodilution and control groups. The proportion of patients that are independent at follow-up does not differ between the groups (odds ratio 0.98). It has not been possible to identify any subgroup in which the therapy is clearly beneficial. Recent pilot clinical studies indicate that the effects of more aggressive hemodilution schemes could be worthwhile to explore. Until the results of new controlled trials are available, it seems that hemodilution has no place in the routine management of patients with ischemic stroke.

ISSN:1015-9770    

DOI:10.1159/000108908

出版商:S. Karger AG    

年代:1991

数据来源: Karger

ISSN:1015-9770    

DOI:10.1159/000108909

出版商:S. Karger AG    

年代:1991

数据来源: Karger

ISSN:1015-9770    

DOI:10.1159/000108910

出版商:S. Karger AG    

年代:1991

数据来源: Karger

ISSN:1015-9770    

DOI:10.1159/000108911

出版商:S. Karger AG    

年代:1991

数据来源: Karger